SACC Sitewhere you are registering child/ren orthe schoolyour child/ren will attend in the fall.

SCHOOL NAME / START DATE:

If you register for more than one SACC site you must pay 2 registration fees

CHILD ONE

CHILD FIRST & LAST NAME / AGE / GRADE 16-17 / DATE OF BIRTH / GENDER

Please check the square to indicate status

Full Time A&P

/ Full Time AM / Full Time PM / Previously enrolled? Yes No
12 Flex A&P / Part Time AM / Part Time PM / Year

CHILD TWO

CHILD FIRST & LAST NAME / AGE / GRADE 16-17 / DATE OF BIRTH / GENDER

Please check the square to indicate status

Full Time A&P

/ Full Time AM / Full Time PM / Previously enrolled? Yes No
12 Flex A&P / Part Time AM / Part Time PM / Year

Child(ren) live(s) withBoth Parents Mother Father Guardian Shared Parenting

Primary Contact Secondary Contact

First Name / First Name
Last Name / Last Name
Home Phone / Home Phone
Address / Address
City/State/Zip / City/State/Zip
Employer Name / Employer Name
Work Phone / Work Phone
Cell Phone / Cell Phone
Email / Email
Party responsible for payment Both Primary Contact Secondary Contact

Would you like a monthly receipt mailed to primary contact.Yes No

*Please complete each blank. Write N/A if items is not applicable

Persons authorized to pick up your child other than parents or guardians.

To deny a non-custodial parent the authority to pick up your child, copies of the court order must be on file.

Name Phone Relationship to Child

1)
2)
3)
4)

MEDICAL RELEASE

If medical care is deemed necessary & I cannot be contacted, I authorize the child care staff, trained in first aid, to act on my behalf in providing appropriate care. I understand I am responsible for updating my contact information.

*AUTHORIZED SIGNATURE / DATE

*Typing your name on this form is your digital signature and gives us authorization to ensure appropriate medical care for your child.

Physician Name / Phone
Dentist Name / Phone
Preferred Hospital

List Any Medical Conditions Requiring Special Attention

SACC Program does not have access to the school’s medical records or medication.

Place N/A in the fields below if they do not apply.

Child’s Name / Child’s Name
Allergies
Diet Considerations
Medications
Special considerations in the care of your child/ren
Your Child/ren Special Area of Interest
Photographic Permission

I do give permission to have my child appear in any media coverage approved by the SACC director. I understand that the Site Coordinator and Program Director has been given authority by the SACC Advisory Board to determine appropriate requests.Typing your name on this form is your digital signature and gives us authorization photograph your child.

*AUTHORIZED SIGNATURE / DATE